Maine Department of Labor

Bureau of Rehabilitation Services

WORKPLACE ASSESSMENT

FOR INDIVIDUALS WITH HEARING LOSS

Name / Date Completed

Please answer the following questions related to your hearing loss and your experience in the workplace. The information will be used to determine accommodations, adjustments, or assistive equipment that will help you to do your job more effectively and with less stress and fatigue.

  1. What type of hearing loss do you have?

Conductive Sensorineural (nerve deafness)

Mixed Don’t know

  1. What is the cause of your hearing loss?
  1. How long have you had a hearing loss?
  1. How would you describe your hearing loss when you were first diagnosed?

Mild Mild to ModerateModerateModerate to Severe

SevereSevere to ProfoundProfoundDon’t Know

  1. Currently, how do you describe your hearing loss without hearing aids?

Mild Mild to ModerateModerate Moderate to Severe

Severe Severe to Profound Profound Don’t Know

  1. When was your last audiogram?
  1. Do you understand how to read your audiogram? Yes No
  2. Do you have a Cochlear Implant? Yes No

If Yes, how long have you had it?

Is your processor: Ear level Body worn

Describe care/repair history:
  1. Do you wear one or two hearing aids?
/ How long have you worn them?
  1. Are your hearing aid?(s) Analog (Traditional) Analog Programmable Digital
  2. What type of hearing aid(s) do you wear? Behind-the-ear In-the-ear In the canal

  1. How old are your current hearing aids?

Describe care/repair history:
  1. Do you wear your hearing aid(s): All the time Part of the time

  1. Doyou have any related physical conditions that add to the communication difficulties that you experience? Explain: e.g., headaches, balance disturbances, dizziness, ringing or other sounds in the ears (tinnitus), or other problems:

On-the-Job Communication Demands

If you are not currently working, please answer the following in accordance to your experience on your last job.

  1. Describe the type of work that you do:

  1. Describe your primary worksite:

  1. Does your job involve travel? Yes No If yes, how often?

  1. Do you work: Part-time Full-time

  1. a. What language do you prefer or use most?

b. How do you most often communicate with people at work? (Check all that apply)
Sign language Finger spelling Speaking & listening Speech reading
Explaining to people how to talk to meWriting / texting (emails, notes, etc.)
  1. Describe communication situations at your work using the table below.
  1. People: Whomdo you communicate with? e.g., bosses, supervisors, co-workers, employees,

supervisees, clients, customers, contractors, trainers, security, custodians, other.

  1. Places: Where does the communication with each of these people usually occur? e.g., at your worksite, someone else’s office, meeting rooms, coffee area, car, etc.
  2. Method: How does the communication with each person occur? e.g., face-to-face, one-on-one, small group, large group, telephone, computer, memo
  3. Frequency: How frequently does communication with each person occur? e.g., several times a day, daily, once a week, month, or year.
  4. Duration: What is the estimated duration of these contacts? e.g., constant, several minutes, a half-hour, hour, several hours, day or days

People / Place / Method / Frequency / Duration
  1. Describe meeting situations you are involved in at work: e.g. how many people attend, seating arrangement, who does the talking, etc.

Telephone communication (if not working, describe home telephone use)

  1. How many times a day do you use the telephone?

  1. Do you use the telephone with your hearing aids? Yes No

If No, explain why:
If Yes, do you have a telecoil (T-switch) on your hearing aid? Yes No
  1. Does your hearing aid squeal when you use the telephone? Yes No

  1. Describe any difficulty you have using the phone:

  1. Describe the make and features of the phone you currently have:

Warning & Alert Sounds

  1. Describe the warning sounds you must be aware of while at work:

  1. Are there warning or alert sounds that are difficult for you to hear?

Barriers to Understanding

Please check the barriers to understanding communication that you experience in the workplace.

  1. Noise:
/ People talking around me Mechanical equipment Electronic equipment
Telephones ringing Fans Traffic Other
  1. Lighting:
/ Too bright Too dim Light behind the speaker
Reflecting light Other
  1. Distractions:
/ Lights flashingSudden soundsSudden movements
Interruptions Background noise Other
  1. Communication Behavior of Others: Not getting your attention before speaking

Speaking too softly Speaking too rapidly Not facing you when speaking
Foreign accentOther:
  1. Location of Work Area: Cubicle walls prevent seeing faces of speakers

Workstation faces away form others Too much sound from other work station
Other:
  1. List the situations that you feel affect your job performance or cause you the most stress:

Aids to Understanding

Please check the answers that apply to your work place or your previous employment.

  1. Which of the following Hearing Assistive Technology devices are in your workplace?
Amplified telephoneVisual or tactile alerting devicesFM system
Infrared SystemInduction LoopStandard MicrophoneTTY
Relay system
  1. Do you use assistive listening devices in any of the following situations?
a. Where there is noise: Yes No
b. Where there is a distance between you and those who are talking? Yes No
c. In meeting situations? Yes No
d. In training situations? Yes No
Comments:
  1. Do you use any of the following types of video display of spoken language?
a. Computer Assisted Real-Time Captioning (CART)? Yes No
b. Videoconferencing? Yes No
c. Captioned videotapes? Yes No
  1. Do you use any alerting devices on the job?
Telephone ringers? Yes No Light Flashers? Yes No
Vibrating Devices? Yes No
Vibrating or flashing alarm clocks? Yes No
  1. Has the work environment been modified in any way to accommodate your hearing loss?
e.g., moving your desk, changing the lighting, removing or installing physical barriers
  1. Have you had speech reading training? Yes No

  1. What communication strategies (e.g., changes in communication behaviors) doyou use to help you understand communication with your employer(s), co-workers and customers?

  1. Would you like to receive assistance or information about any of the following topic areas?

Would like Information / No Interest
Assistive Technology
Coping skills
Hearing aid use and care
Support and networking
Speechreading
  1. Is there other information that you would like to share to provide further understanding of the difficulties you experience in the workplace?

Rev. 7/12

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